A year at U of R

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Wednesday, December 13, 2006

Electro-convulsive therapy

As part of my psych rotation, I accompanied a patient through the entire procedure of electroconvulsive therapy. I was amazed that we were allowed to watch what most people seem to view as horrific and medieval ... intentionally delivering a shock to a patient's brain. However the reality is somewhat different.

The procedure itself is very simple. Preparing the patient takes about an hour, including a baseline set of vitals and inserting an IV for the anesthesia. This is done by a nurse (some of the friendliest I've met in the hospital!), in a consult room. The patient then goes to the waiting room.

When the patient is called from the waiting room, they are taken to the treatment room, a tiny room with a hospital bed. It was crowded with various pieces of discarded machinery. Many of them had labels, "Not Maintained or Functional - Do not use." I had the impression that since ECT outpatient treatment is only scheduled a few days a week, the room doubles as a storage closet. It reminded me of the derelict robots in Star Wars.

The patient lies down on the bed in their street clothes. The only things they need to remove are any dentures or metal jewelry. They are then hooked up to monitors for the heart rate, blood pressure, and oxygen saturation.

An anethesiologist gives them two separate anesthetic agents via IV. One of them "puts the patient to sleep," so they have no memory of the event. The second relaxes the muscles, to prevent injury due to convulsions when the shock is administered. As the muscle relaxant flows into the patient, I could see the patient's leg and arm muscles twitch slightly as the muscle cells depolarized and relaxed. The doctors put an inflated blood pressure cuff around one ankle like a tourniquet, to prevent the relaxant from reaching one foot. This foot would remain reactive, and allow the doctors to observe convulsive activity. The rest of the body was paralyzed.

The scary part to me was that the whole body, including the diaphragm was paralyzed. This means that the patient couldn't breath. A resident at the head of the bed used a manual bag to inflate the patient's lungs, and give them oxygen. To me, however, it seemed like you've essentially "killed" your patient if they no longer breath on their own. The effect wears off in a few minutes after treatment, and the patient is asleep, so they are unaware of it. However it's still a little disturbing to think that you've stopped breathing. Here's my advice if you go for ECT: make sure you've got a great anesthesiologist.

The shock itself is really nothing. It lasts only a second. The electrical stimulation to the brain creates a seizure that lasts an additional 30 seconds. Before the days of anesthesia for ECT, patients would have convulsions strong enough to break bones. Now, because of the muscle relaxant, the patient has no motion during the seizure except their face scrunches up, and their one foot may shake a little. And that's it. At least that's how it's supposed to work.

The day I observed, something went wrong with the IV or the medication. They thought that the patient was fully paralyzed, and adminisered the shock. The patient's face pinched up, and their arms and legs convulsed for the length of the seizure. It looked like other epileptic seizure I've seen. The doctors called the seizure "partially modified." "But," they told me, "we'd like them to be much more modified than that." The only negative result, though, was that the patient might have muscle soreness afterwards.

After the treatment, the patient goes to the recovery room for 1/2 to 1 hour. They come out of anesthesia within about 5 minutes of the treatment. They monitor their vitals (blood pressure often spikes up during ECT), and then the patients go home.

What are my thoughts on ECT after seeing it? There are patients who we've worked with who've been depressed for years, and tried every other treatment. Nothing has worked. The patient may have attempted suicide multiple times, or be so depressed that they can't function or leave their room. Then they go to ECT, and within a day, the veil of depression is lifted. You can visibly see how much alive and better they feel. It is an amazing transformation. How can you argue with a treatment like that? Many psychiatric drugs have numerous severe side effects. ECT has only one ... possible memory loss.

However I wonder how it is being used. Some patients go for a single course of ECT over several months. Some patients have it regularly as an outpatient, once a week, or multiple times a week for years. I have to wonder about the consequences of shocking your brain that often.

Would I personally ever go for ECT? I think I'd rather shock my brain by jumping into an icy lake, eating a bowl of raw jalapeno peppers, bungee jumping off a bridge, or just about anything else instead of ECT.